Fewer infant deaths in a rural South African hospital

Mothers and children in South Africa are still dying in alarming numbers, and the country is among only a few worldwide where child deaths are rising. But a rural hospital in the Eastern Cape province has managed to drastically reduce infant mortality rates over the past six years, against the backdrop of a health system that is virtually at a standstill.

A report on the deepening crisis, launched this week by activists from the newly formed Eastern Cape Health Crisis Coalition, says the freezing of critical posts has contributed to the loss of scarce skills, and some rural facilities have lost more than half of their nursing staff. Chronic shortages of basic medical equipment and essential drugs persist and mobile clinics are no longer running, depriving rural patients of access to essential health services.

Zithulele Hospital in Mqanduli, a town about 30km south of Mthatha, the provincial capital, is the only hospital in an area of nearly 1,000 sq.km, serving a population of about 150,000 that is one of the poorest in the country, with low education levels and very high rates of unemployment and crime. For decades many men left the area to become mine workers and the legacy of the migrant labour system still has a negative impact on the communities living there.

Sihle Tyelinzima, 18, and more than eight months pregnant, is sitting on small wooden bench outside the rondavel (hut) she shares with two other pregnant women. The rondavel, a few hundred metres from the medical wards at Zithulele Hospital, has been her home for nearly two weeks. "I miss being home with my family and friends but I don't regret coming to live at the hospital," Tyelinzima says. "I would rather be homesick than risk losing my baby."

She lives in Mancamu, about 30km away from Zithulele Hospital, one of several villages near Mqanduli. The distance may seem short, but if she were to go into labour while at home, the heavily pregnant Tyelinzima would have to walk over hilly countryside and cross a stream before reaching a road from where an ambulance or a hired car could take her to hospital.

If she should go into labour at night she would have to wait until morning or give birth at home. Home birth is common in the villages around Mqanduli, but in most cases this is because pregnant women don't have transport or can't afford to hire a car to take them to hospital.

A home from home

For this reason the hospital management decided to convert two rondavels once used as nurses’ quarters into homes to accommodate pregnant women nearing the end of their term.

Dr Ben Gaunt, the hospital's clinical manager, noted that the cost of transport prevents even those living close to roads from getting to the hospital in time. "Hiring a car to bring you to hospital from one of the villages can cost between R600 (US$60) and R1,000 (US$100), depending how far you are coming, and for most families this is half of their monthly household income," he said.

The maternal waiting homes have had a positive impact on the perinatal mortality rate at Zithulele hospital. Four years ago, when the concept was introduced, 34 out of 1,000 babies delivered at the facility were dying, but this decreased to about 20 per 1,000 live births last year.

Gaunt said the maternal waiting homes were not the only factor causing significant change to the statistics for perinatal mortality at Zithulele. "There were other important contributors, like reinstituting 24-hour caesarean section service; retraining of midwives; reaching out to our feeder clinics through a system that allowed input into primary level antenatal care, and developing protocols for the safe induction of labour."

In 2005 the hospital faced severe shortages of clinical staff and medical equipment, which worsened a poorly organised maternity service offering sub-standard care. "The maternity service had inexperienced, inadequately supervised staff, and protocols were not properly followed,” he said.

“The partogram (a graphical representation of the changes that occur during labour) was not frequently used; there were shortages of resuscitation equipment, and only two delivery packs with doubtful sterilization in between cases." The arrival of new senior staff members brought welcome changes.

The Perinatal Problem Identification Programme (PPIP), a monthly audit tool managed by the Medical Research Council, was introduced in 2005. The programme allows the user to analyse basic data and identify avoidable factors associated with each perinatal death. These issues as well as obstetric clinical topics and preventive or pre-emptive factors are discussed at monthly meetings.

Reaping the rewards

The efforts are beginning to pay off. "We have been seeing a steady decline in perinatal mortality in the past eight years,” said hospital manager Nonsikelelo Matebese.

Evidence of this success was noted by Gaunt in the February 2010 edition of the South African Medical Journal, when he pointed out in an article that in the last six months of 2005 the perinatal mortality rate had been 49.1 per 1,000 births, but over the same period in 2008 this had dramatically decreased to 22.4 per 1,000 births.

At the time deliveries at the hospital increased from 745 in 2005 to 1,143 in 2008. "The perinatal care index (PCI) - a marker of the quality of care of newborns that corrects for low birth-weight infants - declined from a very high 3.7 during 2006 and 2007 to 2.4 in 2008," Gaunt wrote.

While statistics show that the perinatal mortality rate in Zithulele Hospital has been declining, more needs to be done to ensure that babies don't die from preventable causes. 2013 so far has been difficult for the rural district hospital and the number of perinatal deaths is higher when compared to previous years since the changes were introduced.

Gaunt said four out of about 20 of the deaths in the first six months of 2013 could have been avoided, but attributed this shortcoming largely to challenges that include maintaining equipment, improving relationships with local clinics, integrating care more efficiently, and dealing with the socio-economic factors that influence pregnancy and health-seeking behaviour.